Prescribing

Safety Assessment
Assessment Blueprint June 2016


The Prescribing Safety Assessment has been developed by MSC Assessment and the British Pharmacological Society as a summative
assessment of knowledge, judgement and skills related to prescribing medicines in the NHS. It is intended primarily for medical students at or
near the end of their training and is based on the competencies identified by the General Medical Council in Outcomes for graduates (2015)
(originally published in Tomorrows Doctors (2009)). The PSA is delivered as an on-line assessment. It assesses, as far as possible, within the
confines of a virtual environment, complex skills including powers of deduction and problem solving that are relevant to the work of
Foundation (Year 1) doctors in the NHS.

The assessment comprises eight sections, each containing a specific item style. There are either six or eight individual items in each section.
The assessment offers a total of 200 marks and candidates are expected to complete it within a total of two hours of examination time (Figure
1). The 8 item styles assess prescribing, prescription chart review, planning management, providing important information to patients, drug
calculation skills, adverse drug reactions, monitoring therapy and data interpretation. These are described in more detail below (Appendix A)
and some examples of scenarios are included in a grid that maps the item styles to relevant clinical settings for a Foundation doctor (Appendix
B). They reflect not only the process of prescribing but also the related skills, judgement and knowledge required to review, advise and provide
information about medicines. A sampling matrix (Appendix C) is completed for each assessment build to ensure that each assessment contains
the correct number of items of each style, and meets the required standard for coverage of clinical settings and high-risk drugs.

The skills assessed by the item styles reflect the requirements of Outcomes for graduates (2015) (Appendix D), (referenced in Promoting
excellence; standards for medical education and training (2015)(Appendix E)) and the Safe Prescribing Working Group recommendations about
the competency requirements of all Foundation doctors (Appendix F).

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Figure 1. Content of the assessment

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Appendix A. Item styles

PRESCRIBING

Reasoning and Judgement: Deciding on the most appropriate prescription (drug, dose, route and frequency) to write, based on the
clinical circumstances and supplementary information

Measureable Action: Writing a safe, effective and legal prescription for a single medicine using the documentation provided, to tackle a
specific indication highlighted by the question

This item style presents a clinical scenario followed by a request to prescribe a single appropriate medicine or fluid. It is distinct from other
styles by the requirement to write a prescription on one of a variety of prescription charts. Typical scenarios involve the treatment of acute
problems (e.g. acute asthma attack, acute heart failure), chronic problems (e.g. depression, reflux oesophagitis), and important symptoms
such as pain. The candidate must exercise judgement when deciding between different drugs, different formulations, different routes,
different doses, and different durations. Prescriptions are expected to meet appropriate standards, they must be unambiguous and
complete (approved name of drug, appropriate form and route, correct dose, date/time and signature). The duration of treatment (e.g. 7
or 28 days) is included in all General Practice forms as there is no facility for the candidate to specify a quantity to supply.

There are eight Prescribing items in the assessment, each of which includes a single question requiring a single prescription to be written.
Each item is worth 10 marks (4 for the drug choice, 4 for the choice of dose/route/frequency, 1 for the correct timing and 1 for the
signature, making a total of 80 marks for this item style).

The purpose is to demonstrate the ability to write a safe and effective prescription [TD 17(c)][SPWG 3], to manage acute medical
emergencies [TD 16(b)], and to plan appropriate drug therapy for common indications [TD 8(e) and 17(b)][SPWG 2].

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PRESCRIPTION REVIEW

Reasoning and Judgement: Deciding which components of the current prescription list are inappropriate, unsafe or ineffective for a
patient based on their clinical circumstances

Measureable Action: Identifying prescriptions (drugs, doses or routes) that are inappropriate, unsafe or ineffective from amongst the
current list of prescribed medicines

This item style presents a scenario that requires review of a current list of prescribed medicines (e.g. an inpatient prescription chart, a
referral letter from a general practitioner). Typically this item style involves interpreting the list of medicines in light of a clinical problem
(e.g. impaired renal function, loss of anticoagulation control, headache), spotting important drug interactions (e.g. verapamil with beta-
blockers, erythromycin with warfarin), identifying obvious or serious dosing errors (e.g. morphine, digoxin, aspirin), or noting suboptimal
prescriptions (e.g. loop diuretics prescribed for late in the day, ineffective doses). The total list of medicines for each item ranges from 6 to
10. Some knowledge of common effects, adverse reactions and interactions of common medicines is assumed. Candidates should have
time to consult the BNF for relevant information that might be considered beyond the core knowledge base of a minimally competent
Foundation doctor.

There are eight Prescription Review items in the assessment, each of which includes two questions requiring analysis of a list of currently
prescribed drugs. Each item is worth 4 marks (making a total of 32 marks for this item style).

The purpose is to demonstrate the ability to review the prescribing of others [TD 21(c)][SPWG 4], to spot potentially important errors and
make changes that will improve patient outcome [TD 23(d)].

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PLANNING MANAGEMENT

Reasoning and Judgement. Deciding which treatment would be most appropriate to manage a particular clinical situation

Measureable Action: Selecting the most appropriate treatment based on individual patient circumstances

This item style presents a clinical scenario followed by a request to identify the most important treatment that would be part of initial
management. This involves selecting between options (medicines, fluids and sometimes other treatments) that would be of real benefit
and others that would be neutral or harmful. The candidate must decide on the most appropriate treatment, based on symptoms, signs,
and investigations, from a list of five. Such treatment might be preventive, curative, symptomatic, or palliative. The candidate should show
that they are able to plan treatment that is appropriate to individual patients. They should be aware of situations where it is inappropriate
to treat and also of the role of non-drug therapies (e.g. physiotherapy, TENS machines for pain relief). Some of these scenarios may relate
to the management of clinical toxicological emergencies. The likely diagnosis (or differential diagnosis) should be clear from the scenario
but will not necessarily be identified, to reflect the fact that planning management is sometimes necessary when there remains a degree of
uncertainty about the underlying diagnosis (e.g. dyspnoea, abdominal pain, reduced conscious level).

There are eight Planning Management items in the assessment, each of which requires identification of the most appropriate treatment
from a list of five. Each item is worth 2 marks (making a total of 16 marks for this item style).

The purpose is to demonstrate the ability to plan appropriate treatment for common clinical indications [TD 8(e), 14(g) and 17(b)][SPWG
2].

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PROVIDING INFORMATION

Reasoning and Judgement: Deciding what is the important piece of information that should be provided to patients to allow them to
choose whether to take the medicine and to enhance its safety and effectiveness

Measureable Action: Selecting the information that is most important

This item style presents a brief scenario in which a patient is about to start taking a new treatment or has come to ask advice about an
existing treatment. The candidate is expected to select the most important piece of information that they would give to the patient from a
list of 5 that includes four distractors. Examples of the medicines that might be the focus of discussion include insulin, warfarin, salbutamol
inhaler, methotrexate, or an oral hypoglycaemic.

There are six Providing Information items in the assessment, each of which requires identification of the most important information
option from a list of five. Each item is worth 2 marks (making a total of 12 marks for this item style).

The purpose is to demonstrate the ability to provide patients with important information about their medicines [TD 14(g) and 17(e)][SPWG
6].

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CALCULATION SKILLS

Reasoning and Judgement: Making an accurate drug dosage calculation based on numerical information

Measureable Action: Recording the answer accurately with appropriate units of measurement

This item style presents a scenario where the candidate has to make an accurate calculation of the dose or rate of administration of a
medicine. They must interpret the problem correctly and use basic arithmetic to derive the correct answer. Examples of potential scenarios
might include identifying the correct number of tablets to achieve a required dose, making necessary dose adjustments based on weight or
body surface area, or diluting a drug for administration in an infusion pump. These items also include testing the candidates ability to
recognise and convert different expressions of drug doses and concentrations.

There are eight Calculation items in the assessment, each of which requires calculation of the correct figure based on a very brief clinical
scenario. Each item is worth 2 marks (making a total of 16 marks for this item style).

The purpose is to demonstrate the ability to calculate appropriate drug doses and record the outcome accurately [TD 17(d)][SPWG 5].

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ADVERSE DRUG REACTIONS

Reasoning and Judgement: Identifying likely adverse reactions to specific drugs, drugs that are likely to be causing specific adverse drug
reactions, potentially dangerous drug interactions and deciding on the best approach to managing a clinical presentation that results
from the adverse effects of a drug

Measureable Action: Selecting likely adverse reactions of specific drugs, selecting drugs to discontinue as likely causes of specific
reactions, avoiding potential drug-interactions and providing appropriate treatment for patients suffering an adverse event

Type A. This item style requires the candidate to identify the most likely adverse effect of a specific drug. Examples might include the
adverse effects caused by commonly prescribed drugs such as calcium channel blockers, beta2-agonists, non-steroidal anti-inflammatory
drugs, aminoglycoside antibiotics, etc.

Type B. This item style requires the candidate to consider a presentation that could potentially be caused by an adverse drug reaction and
identify the medicine most likely to have caused the presentation. Examples might include newly recognised renal impairment, hepatic
dysfunction, hypokalaemia, urinary retention, etc.

Type C. This item style requires the candidate to consider a presentation where there are potential interactions between medicines
currently being prescribed to a patient and identify the drug most likely to be clinically important. Examples might include interactions such
as warfarin-statins, NSAIDs-ACE inhibitors etc.

Type D. This item style requires the candidate to consider a presentation where a patient is suffering an adverse drug event and decide on
the most appropriate course of action. Examples might include acute anaphylaxis, excessive anticoagulation, drug-induced hypoglycaemia,
diuretic-induced dehydration etc.

There are eight Adverse Drug Reaction items in the assessment, each of which requires identification of the most appropriate answer from
a list of five. Each item is worth 2 marks (making a total of 16 marks for this item style).

The purpose is to demonstrate the ability to detect, respond to and prevent potential adverse drug reactions [TD 17(g) and 23(e)] [SPWG 8],
and access reliable information about medicines [TD 17(f)][SPWG 7].

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TDM

DRUG MONITORING

Reasoning and Judgement: Deciding on how to monitor the beneficial and harmful effects of medicines.

Measureable action: Identifying the appropriate methods of assessing the success or failure of a therapeutic intervention.

This item style presents a scenario that involves making a judgement about how best to assess the impact of treatments that are ongoing
or are being planned. Candidates are expected to demonstrate that they understand how to plan appropriate monitoring for beneficial and
harmful effects based on factors such as clinical history, examination and investigation. This may involve taking blood samples at the right
time, deciding which is the most appropriate assessment of outcome, the timing of those measurements. Examples of prescriptions that
might require appropriate monitoring are digoxin for atrial fibrillation, inhaled corticosteroids for asthma, oral contraception, thyroxine for
hypothyroidism, etc.

There are eight Monitoring items in the assessment, each of which requires identification of the most appropriate answer from a list of
five. Each item is worth 2 marks (making a total of 16 marks for this item style).

The purpose is to demonstrate knowledge of how drugs work and their clinical effects [TD 8(f)] and the ability to monitor them
appropriately to maximise safety and efficacy.

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DATA INTERPRETATION

Reasoning and Judgement: Deciding on the meaning of the results of investigations as they relate to decisions about ongoing drug
therapy

Measureable Action: Making an appropriate change to a prescription based on those data

This item style involves interpreting data in the light of a clinical scenario and deciding on the most appropriate course of action with
regard to prescribing. This may involve withdrawing a medicine, reducing its dose, no change, increasing its dose or prescribing a new
medicine. The key focus of these items is interpreting the data and deciding on its implications for prescribing. Examples of data to be
considered might include drug concentrations, haemoglobin, white cell count, liver or renal function, cholesterol, nomograms, etc.

There are six Data Interpretation items in the assessment, each of which requires identification of the most appropriate answer from a list
of five. Each item is worth 2 marks (making a total of 12 marks for this item style).

The purpose is to demonstrate the ability to interpret data on the impact of drug therapy and make appropriate changes, and critically
appraise the results of relevant diagnostic, prognostic and treatment trials [TD 12(a)].

Detailed descriptions of the skills being assessed and how then are blueprinted against relevant national statements of core competencies are
listed (TD = Outcomes for graduates (2015) (from Tomorrows Doctors 2009) , SPWG = Medical Schools Council Safe Prescribing Working
Group 2007).

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Notes on Clinical Settings

General Medicine: This setting includes acute medical admissions units, cardiovascular, respiratory, gastroenterology, neurology,
rheumatology conditions as well as common medical emergencies.
General Surgery: This setting includes pre-operative and post-operative therapeutics relating to general surgery, orthopaedic, colorectal
surgery etc.
Elderly Care: This setting involves elderly patients with problems such as stroke, incontinence and cognitive impairment and includes the
problems posed by polypharmacy.
Paediatrics: This setting involves children under the age of 16 including neonatal care.
Psychiatry: This setting includes patients with common psychiatric problems such as anxiety, depression, disturbed behaviour and psychosis.
Obstetrics & Gynaecology: This setting includes the care of women who are pregnant (or who are planning to become pregnant), women who
are using or requesting contraception and those with common gynaecological problems.
General practice: This setting involves the problems most commonly encountered in a primary care setting including ear, nose & throat
problems, dermatology, and ophthalmology.

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Appendix B. Examples of clinical cases and related item styles

Prescribing
Prescription review
Planning
management
Providing
information

Medicine

Surgery

Elderly Care

Paediatrics

Psychiatry

Obstetrics &
Gynaecology

General
Practice

Unstable angina
Acute asthma
Dyspepsia

Thromboprophylaxis
Antibiotics
Analgesia

Intravenous fluids
Laxatives
Analgesia

Depression
Anxiety

Pre-operative
assessments
NBM

SSRIs
Lithium

Oral contraception
HRT
Bladder instability

Reviewing prescribing in
pregnancy
Interactions with OCP

Hypercholesterolaemia
Hypertension
Urinary tract infection

Interactions
Medication errors
Causes of signs and
symptoms
Acute (e.g. asthma,
pulmonary oedema,
MI), Chronic (e.g.
COPD, diabetes)

Allergies
Infection (e.g. otitis
media, epiglottitis,
croup), Reflux
Cases of polypharmacy
in children will be more
difficult to find
Asthma
Acute anaphylaxis
Diabetic ketoacidosis
Dehydration

Vaccinations
Insulin
Cystic fibrosis
Acne

Acute behavioural
disturbance

Anticoagulation,
UTI in pregnancy

Shingles
Community acquired
pneumonia

Antidepressants
Benzodiazepines
Antipsychotics

Fluid replacement
Dosing by weight
Buccal midazolam

Advising about drugs in

breast feeding
Advising about drugs
preconception
OCP, HRT
Lidocaine injections

Antihypertensives
Nicotine replacement
NSAIDs, latanoprost
Sildenafil
Vaccinations
Steroid reducing dose

Oestrogenic effects
Interactions with the
OCP

Headache
Ankle swelling
Dizziness
Lethargy

Calculation skills
Adverse drug
reactions
Drug monitoring
Data interpretation

Renal impairment
Liver function
Hyponatraemia
Digoxin, insulin,
methotrexate,
amiodarone, oxygen
TFTs, glucose, INR,
renal function

Diuretics
Antihypertensives
Benzodiazepines
Opioids
Acute (e.g. back pain)
Chronic (e.g.
Parkinsons disease,
dementia)

Acute (e.g. bleeding,

low BP, acute abdo)
Chronic (e.g. IBD,
oncology)

Oral hypoglycaemics
Corticosteroids
Nitrates

Aminophylline
infusion

Tamoxifen
Antibiotics
Heparin
Finasteride

Anticoagulants
Bisphosphonates
Diuretics
Anti-epileptics
Hypnotics
Digoxin elixir

Infusion rates (e.g.

dopamine),
intravenous fluid
volumes
Bleeding
Opioid toxicity
Vomiting

Fluid replacement
Blood transfusion
Antibiotics
Anticoagulants
Antibiotic
concentrations
Fluid replacement

Patients presenting
with common
symptoms

Dehydration
Collapse
Constipation

Hypoglycaemia
Vomiting
Substance abuse

Intravenous
lorazepam
Haloperidol
injection
Benzodiazepines
Antimuscarinic
effects
Antipsychotics

Carbimazole
Theophylline
Anti-epileptics

Asthma therapy
Diabetes

Lithium
Antipsychotic drugs

Monitoring safety of
OCP

Statins
ACE inhibitors
Antibiotics

Hb, U&Es, CXR, anti-

epileptic
concentrations

PEFR, paracetamol
poisoning

Lithium
concentration

BP and OCP
HRT and LFTs

Cholesterol, BP,
+
diuretics and K

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Appendix C
Sampling matrix to be completed for each assessment build

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Appendix D
General Medical Council Outcomes for graduates (2015) (from Tomorrows Doctors (2009))
Outcomes relating to prescribing medicines
Outcomes for graduates
Outcomes 1 - The doctor as a scholar and a scientist
(8) The graduate will be able to apply to medical practice biomedical scientific principles, method and knowledge relating to: anatomy, biochemistry, cell
biology, genetics, immunology, microbiology, molecular biology, nutrition, pathology, pharmacology and physiology. The graduate will be able to:
(a) Explain normal human structure and functions.
(b) Explain the scientific bases for common disease presentations.
(c) Justify the selection of appropriate investigations for common clinical cases.
(d) Explain the fundamental principles underlying such investigative techniques.
(e) Select appropriate forms of management for common diseases, and ways of preventing common diseases, and explain their modes of action and their risks
from first principles.
(f) Demonstrate knowledge of drug actions: therapeutics and pharmacokinetics; drug side effects and interactions, including for multiple treatments, long term
conditions and non-prescribed medication; and also including effects on the population, such as the spread of antibiotic resistance.
(g) Make accurate observations of clinical phenomena and appropriate critical analysis of clinical data.
(12) Apply scientific method and approaches to medical research.
(a) Critically appraise the results of relevant diagnostic, prognostic and treatment trials and other qualitative and quantitative studies as reported in the
medical and scientific literature.
(b) Formulate simple relevant research questions in biomedical science, psychosocial science or population science, and design appropriate studies or
experiments to address the questions.
(c) Apply findings from the literature to answer questions raised by specific clinical problems.
(d) Understand the ethical and governance issues involved in medical research.

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Outcomes 2 - The doctor as a practitioner

(14) Diagnose and manage clinical presentations.
(a) Interpret findings from the history, physical examination and mental-state examination, appreciating the importance of clinical, psychological, spiritual,
religious, social and cultural factors.
(b) Make an initial assessment of a patients problems and a differential diagnosis. Understand the processes by which doctors make and test a differential
diagnosis.
(c) Formulate a plan of investigation in partnership with the patient, obtaining informed consent as an essential part of this process.
(d) Interpret the results of investigations, including growth charts, x-rays and the results of the diagnostic procedures in Appendix 1.
(e) Synthesise a full assessment of the patients problems and define the likely diagnosis or diagnoses.
(f) Make clinical judgements and decisions, based on the available evidence, in conjunction with colleagues and as appropriate for the graduates level of
training and experience. This may include situations of uncertainty.
(g) Formulate a plan for treatment, management and discharge, according to established principles and best evidence, in partnership with the patient, their
carers, and other health professionals as appropriate. Respond to patients concerns and preferences, obtain informed consent, and respect the rights of
patients to reach decisions with their doctor about their treatment and care and to refuse or limit treatment.
(h) Support patients in caring for themselves.
(i) Identify the signs that suggest children or other vulnerable people may be suffering from abuse or neglect and know what action to take to safeguard their
welfare.
(j) Contribute to the care of patients and their families at the end of life, including management of symptoms, practical issues of law and certification, and
effective communication and teamworking.
(16) Provide immediate care in medical emergencies.
(a) Assess and recognise the severity of a clinical presentation and a need for immediate emergency care.
(b) Diagnose and manage acute medical emergencies.
(c) Provide basic first aid.
(d) Provide immediate life support.
(e) Provide cardio-pulmonary resuscitation or direct other team members to carry out resuscitation.
(17) Prescribe drugs safely, effectively and economically.
(a) Establish an accurate drug history, covering both prescribed and other medication.
(b) Plan appropriate drug therapy for common indications, including pain and distress.
(c) Provide a safe and legal prescription.
(d) Calculate appropriate drug doses and record the outcome accurately.
(e) Provide patients with appropriate information about their medicines.

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(f) Access reliable information about medicines.

(g) Detect and report adverse drug reactions.
(h) Demonstrate awareness that many patients use complementary and alternative therapies, and awareness of the existence and range of these therapies, why
patients use them, and how this might affect other types of treatment that patients are receiving.
(18) Carry out practical procedures safely and effectively.
(a) Be able to perform a range of diagnostic procedures, as listed in Appendix 1 and measure and record the findings.
(b) Be able to perform a range of therapeutic procedures, as listed in Appendix 1.
(c) Be able to demonstrate correct practice in general aspects of practical procedures, as listed in Appendix 1.
Outcomes 3 - The doctor as a professional
(21) Reflect, learn and teach others.
(a) Acquire, assess, apply and integrate new knowledge, learn to adapt to changing circumstances and ensure that patients receive the highest level of
professional care.
(b) Establish the foundations for lifelong learning and continuing professional development, including a professional development portfolio containing
reflections, achievements and learning needs.
(c) Continually and systematically reflect on practice and, whenever necessary, translate that reflection into action, using improvement techniques and audit
appropriately for example, by critically appraising the prescribing of others.
(d) Manage time and prioritise tasks, and work autonomously when necessary and appropriate.
(e) Recognise own personal and professional limits and seek help from colleagues and supervisors when necessary.
(f) Function effectively as a mentor and teacher including contributing to the appraisal, assessment and review of colleagues, giving effective feedback, and
taking advantage of opportunities to develop these skills.
(23) Protect patients and improve care.
(d) Promote, monitor and maintain health and safety in the clinical setting, understanding how errors can happen in practice, applying the principles of quality
assurance, clinical governance and risk management to medical practice, and understanding responsibilities within the current systems for raising concerns
about safety and quality.
(e) Understand and have experience of the principles and methods of improvement, including audit, adverse incident reporting and quality improvement, and
how to use the results of audit to improve practice.

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Appendix 1 Practical procedures for graduates

Therapeutic Procedures
16. Administering oxygen Allowing the patient to breathe a higher concentration of oxygen than normal, via a face mask or other equipment.
17. Establishing peripheral intravenous access and setting up an infusion; use of infusion devices Puncturing a patients vein in order to
insert an indwelling plastic tube (known as a cannula), to allow fluids to be infused into the vein (a drip). Connecting the tube to a source of
fluid. Appropriate choice of fluids and their doses. Correct use of electronic devices which drive and regulate the rate of fluid administration.
18. Making up drugs for parenteral administration Preparing medicines in a form suitable for injection into the patients vein. May involve
adding the drug to a volume of fluid to make up the correct concentration for injection.
19. Dosage and administration of insulin and use of sliding scales Calculating how many units of insulin a patient requires, what strength of
insulin solution to use, and how it should be given (for example, into the skin, or into a vein). Use of a sliding scale which links the number of
units to the patients blood glucose measurement at the time.
20. Subcutaneous and intramuscular injections Giving injections beneath the skin and into muscle.
21. Blood transfusion Following the correct procedures to give a transfusion of blood into the vein of a patient (including correct identification
of the patient and checking blood groups). Observation for possible reactions to the transfusion, and actions if they occur.
23. Instructing patients in the use of devices for inhaled medication Providing instructions for patients about how to use inhalers correctly,
for example, to treat asthma.
24. Use of local anaesthetics Using drugs which produce numbness and prevent pain, either applied directly to the skin or injected into skin or
body tissues.

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Appendix E

General Medical Council - Promoting excellence: standards for medical education and training July
2015.
Theme 5: Developing and implementing curricula and assessments
The GMC sets the learning outcomes required of medical students when they graduate and the standards that medical schools must meet when
teaching, assessing and providing learning opportunities for medical students.
Medical schools develop and implement curricula and assessments to make sure that medical graduates can demonstrate these outcomes.
Medical schools, in partnership with LEPs, also make sure that clinical placements give medical students the learning opportunities they need to
meet these outcomes. Medical schools are responsible for the quality of assessments including those done on their behalf. Medical schools make
sure only medical students who demonstrate all the learning outcomes are permitted to graduate

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Appendix F
Medical Schools Council Safe Prescribing Working Group
Statement of Competencies in relation to Prescribing required by all Foundation Doctors
Prescribing is a core clinical skill practised regularly by all qualified doctors from day one of their first Foundation post. Effective prescribing
can yield great benefits for patients, but medicines are also associated with significant risks. Adverse medication events are common in NHS
hospitals. The task of prescribing well is probably getting more difficult, owing to various factors. For all of these reasons it is important that
undergraduate medical education delivers a firm grounding in the principles of therapeutics and is supported by appropriate knowledge and
practical skills.
To guide the undergraduate learning process the Medical Schools Council Safe Prescribing Working Group has agreed a set of competencies
required of all doctors at the beginning of their Foundation training. These take into account the likely prescribing demands and levels of
supervision possible in a typical NHS hospital. Although not explicitly stated, the competencies are also applicable to prescription of other
therapies such as oxygen, intravenous fluids and blood products.
Competencies required of all Foundation doctors
1. The ability to establish an accurate drug history. This may be taken directly from the patient, from a collection of medicines, or from
information given by others (carers, GP, old prescriptions). The record of this history should include making relevant conclusions from past
exposures, including effective interventions and unsuccessful or harmful ones (drug allergies, adverse drug reactions, and drug interactions).
2. The ability to plan appropriate therapy for common indications. This means deducing appropriate treatment, based on symptoms, signs, and
investigations. Such treatment might be preventive, curative, symptomatic, or palliative. It should be possible to plan treatment that is
appropriate to individual patients. This will involve deciding at a simple level between options that might include different drugs, different
formulations, different routes, different doses, and different durations. It should be possible to plan treatment for common acute and chronic
conditions, including the use of high-risk drugs (e.g. anticoagulants, opioids, insulin) and commonly used antibiotics. There should be
awareness of situations where it is inappropriate to prescribe and also of the role of non-drug therapies (e.g. physiotherapy, TENS machines
for pain relief).

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3. The ability to write a safe and legal prescription. This will usually be on a hospital drug administration chart (once-only, regular, and as
required medications), but may include other relevant documentation (e.g. an infusion chart, insulin chart, warfarin chart, oxygen chart, TTO
prescriptions). This skill would also include cancelling prescriptions and understanding other aspects of documentation. Prescriptions would
be expected to meet appropriate standards, being legible, unambiguous, and complete (approved name written in upper case, appropriate
form and route, correct dose appropriately written without abbreviations, necessary details and instructions, signed). It should be possible to
prescribe controlled drugs. This skill would normally be undertaken with access to a copy of the British National Formulary. Prescribers
should be aware of the legal responsibility of signing a prescription.
4. The ability to appraise critically the prescribing of others. This will include the ability to review prescription charts and relate medicines to
symptoms (e.g. a nitrate and headache), identify common drug interactions (e.g. erythromycin with warfarin), identify inappropriate
prescriptions (e.g. a hypnotic during daytime), and identify obvious dosing errors for common drugs (e.g. aspirin). By implication, all doctors
should also be able to review and critically appraise their own prescribing decisions.
5. The ability to calculate appropriate doses. These might include simple dosage calculations by weight or body surface area and adjustments
for age or renal function. This will include knowledge of different expressions of drug doses.
6. The ability to provide patients with appropriate information about their medicines. This will include being able to provide important
information about the most commonly prescribed drugs or groups of drugs (approximately 75 in all), being able to help patients make
informed decisions about their care, and being able to give instructions that improve safety and effectiveness (e.g. safety warnings about
warfarin, explanations about inhaled therapy).
7. The ability to access reliable information about medicines. This might include standard hard-copy references, such as the BNF and the
Datasheet/SPC compendium, but will increasingly involve an electronic search. This would involve being able to check for
contraindications, drug-drug interactions, and known adverse drug reactions.
8. The ability to detect and report adverse drug reactions. This should include recognition of specific types of drug-induced disease, such as
anaphylaxis, maculopapular rash, bone marrow suppression, liver disorders, kidney disease. It should also include the ability to report an
adverse drug reaction and awareness of sources of information on adverse drug reactions.
November 2007
Available to download at www.medschools.ac.uk

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Prescribing Safety Assessment Blueprint (30.06.2016)

Acknowledgements
Based on the original version created by Professor Simon Maxwell (May 2010).

Revised Edition (June 2016) updated and reviewed by Professor Simon Maxwell (Medical Director, PSA) & Dr Lynne Bollington (Lead
Consultant, PSA).

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